Many say Medicare action too heavy-handed

Doctors and officials at Haywood Regional Medical Center are accusing state inspectors of being heavy-handed, draconian, unprecedented, dangerous and unfair by pulling the hospital’s Medicare and Medicaid status.

It will be a month at least, and possibly four, before Medicare and Medicaid payments are restored at the hospital. The violations that led to the current crisis all revolved around medication being improperly administered to patients by nurses (see Timeline of a crisis, page 9). Hospital officials and doctors call the violations minor, however, and emphasize that no patients were seriously injured or died as a result of the errors.

“We have not had a death or major issue due to meds,” said David Rice, who just resigned as CEO of the hospital. “I can stand behind my nursing staff very strongly.”

For example, the hospital was written up when one nurse didn’t wash her hands before administering a patient’s medication, Rice said. Another violation occurred when a nurse placed a check in the medication column on the patient’s chart as she walked into their room with their pills in hand. However, the nurse should have waited until the patient actually took the meds to check it off on their chart.

In another violation, a medication was supposed to be delivered through a drip IV. Instead, the nurse injected it with a syringe.

“She didn’t jeopardize the safety of the patient. She did no harm. She just administered it differently,” Rice said.

Dr. Henry Nathan said the hospital’s punishment seems out of line with the violations.

“Say you give medicine intravenously using a syringe instead of hanging it in a plastic bag and letting it drip. It is technically an error, but does it make any difference at all to the patient?” posed Nathan. “No, it doesn’t. Because of a series of things like that, should you shut down the county’s only hospital and punish the patients and employees and all sorts of other people?”

Nathan said the state’s actions will cause more potential harm to patients than the medication errors. Forcing Medicare patients to be transported long distances to other hospitals for medical care puts them at risk, Nathan said.

“The regulating agency is out of control. Their action is not safeguarding the health of Haywood County citizens,” Nathan said. “This is an unprecedented and draconian punishment for infractions that aren’t really that horrible. They are not trivial, but the punishment is way out of line with the offense. It is really like shooting a mouse with a cannon, and none of us understand why that is happening.”

Dr. Richard Steele, a urologist and a hospital board member, had a similar analogy.

“It’s like running a stop sign and getting the death penalty,” said Steele. “I was taken aback by the seriousness of the penalty. I’m extremely puzzled by their judgment.”

Rice said the hospital does not agree with the inspectors’ ruling. The inspectors agree with the hospital on one count — that revoking a hospital’s Medicare and Medicaid status is indeed unprecedented.

“What I can tell you is this. It’s not uncommon for us to send out a termination notice, but it is very rare for a facility to have its funding terminated,” said Lee Millman, spokesperson for the Division of Survey and Certification, the federal agency that oversees Medicare.

In other words, lots of hospitals get violations and warnings, but few fail their follow-up inspections and actually get the plug pulled.

Out of 6,700 hospitals in the nation, only five last year had Medicare revoked.

“It’s not common,” said Dalton.

The punishment seems so overboard for the type of infractions that it caused some physicians to wonder whether they have the full story.

“I’ve never been afraid to speak very highly of our hospital. Is there something else going on here that we don’t know about?” Dr. Mark Kinter asked during a meeting between doctors and hospital officials Monday night.

Rice said no, that the inspectors are really that petty.

Though many HRMC physicians are defending the hospital, at least one doctor is making accusations of more dire errors. Dr. Aloha Bryson, who lodged a complaint with the state last December and kicked off the inspections that led to the Medicare and Medicaid crisis, claims patients died as a result of medication errors. But that is completely untrue, Rice told a gathering of doctors Monday night.

“You are going to see these accusations out there,” Rice warned doctors. “You don’t deserve that kind of comment.”

Rice said nurses do not deserve the criticism either.

Fixing the problems

Doctors feel it is unfair that all the services tied to the hospital are being punished for medication infractions that happened in a different department unrelated to their practice. For example, Dr. David Markoff can’t perform cataract surgeries now because of problems dispensing medication in another part of the hospital.

“I don’t feel there is anything unsafe about doing surgery, but because of the problems on the inpatient side it is affecting all of us,” Markoff said.

During the meeting of doctors Monday night, Dr. Robin Matthews, an ob-gyn, asked whether the hospital has any recourse. The hospital’s attorney, Phil Smith, replied that the hospital has a very good case for a legal challenge against the state and federal inspectors. The hospital board discussed the merits of legal action during a board meeting Monday, but decided against it, Smith said.

“We could spend money on lawyers or get a consulting firm to come in here and do a 360,” Smith said. “Wouldn’t the money be spent better that way than paying lawyers?”

Indeed, that’s just what the hospital board is doing. On Tuesday, a national consulting firm called Compass Consulting Group arrived with the promise of pulling the hospital out of this mess. They plan to train nurses in new protocols and procedures so the hospital can pass a new inspection and get its Medicare-Medicaid status back.

The hospital had been trying to do that on its own. Following the first inspection in late January, the hospital launched an aggressive plan to implement new protocols and train nurses in proper procedures for administering meds. The inspectors OK’d the hospital’s new protocols for administering medication, leading hospital officials to believe they would be cleared of their violations during a follow-up inspection, Rice said. But the opposite happened. During the follow-up visit, inspectors found that while the new protocols were OK, they weren’t being properly followed.

“We felt our new plan for medication administration would bear out, and we had documented the re-education of employees. We thought we had a good case,” said Rice. “Our plan, our process was approved as a plan that should have worked, but they said it did not meet expectations.”

“The medicine distribution was greatly improved. My disappointment is that the state did not recognize that,” Rice said.

The hospital does not deny there were problems.

“I’ll be frank with you. Looking at the data, there is room for improvement,” hospital attorney Phil Smith told a meeting of doctors Monday night.

Rice said although the errors were minor, failure to follow protocols could lead to more serious problems.

“They are minor errors, but when you have an error, you could make one that’s not minor,” Rice said.

The errors at Haywood seem minor compared to the mistakes at Duke Medical Center when cleaning fluid was accidentally run through patient’s IV, Smith said, or when an organ transplant killed a patient because it was the wrong blood type, which also occurred at Duke. In that case, the hospital received a warning but no revocation.

When HRMC failed its second follow-up inspection last Friday, it enlisted the help of Mission Hospital in Asheville, which sent a team of nurses and pharmacists to Haywood over the weekend.

“They were with us all night trying to remedy some of the problems,” said Dr. Shannon Hunter, hospital chief of staff.

Rice said the nursing staff has “been through hell in the past 10 days.” Rice called one inspector “obstinate and rude,” bringing one nurse to tears.

“When you upset one of our staff members to the point of tears who is trying to administer meds, you are asking for an issue,” Rice said.

During an address to doctors Monday night, Rice asked them to be supportive of nursing.

“The nursing staff has gone through a lot of trauma in the past two weeks,” Rice said. “And for goodness sake, write it so they can read it and write it in the right place, not on the side of the charts.